Microsoft word - dental and medical information form
DENTAL AND MEDICAL INFORMATION
Date_______________ Patient’s Name __________________________________________
Have you ever had any serious trouble associated with previous dental treatment? If so, please
Does dental treatment make you nervous? ___ No ___ Slightly ___Moderately ___Extremely
Correct answers to the following questions will allow your dentist to treat you on a more individual basis, providing the care appropriate for your particular needs. Your answers are for our records only and will be considered confidential.
Yes No Yes No
Is it important for you to keep your teeth?
Have you had injury to your head, neck or jaw?
Are you dissatisfied with the appearance of your
Is there anything about having dental treatment that
Does food tend to get caught between your teeth?
Wore a bite plate or other appliance?
Do your gums often bleed while brushing?
Are you having dental pain at this time?
Are you wearing removable dental appliances?
Has anyone in your family ever had gum treatment?
Have you noticed any loosening of teeth?
Have you ever had periodontal treatment? If so,
Have you ever had excessive bleeding following
an extraction, or do cuts take longer to heal?
Do you clench your teeth while awake or asleep? Do you get frequent blisters on your lips/mouth?
Do you bite your lips or cheek frequently?
Do you get frequent swelling/lumps in mouth?
How often do you brush________________
Have you noticed pain (joint, ear, side of face)?
Have you noticed difficulty in opening or closing?
Have you noticed difficulty in chewing?
Please explain if you answered “YES” to, or are uncertain about, any of the questions above: _______________________________________________________________________________
Physician name______________________________ Date of last physical exam_____________
Physician address ________________________________________________________________
Has there been any change in you general health in the past year? ___Yes ___No
Are you are under the care of a physician? If so, describe ________________________________
Have you had any serious illness within the past 5 yrs? If so, describe ______________________
Yes No Yes No Yes No
Do you have or have you
Are you allergic to, or have
had any of the following
you had any reactions to:
Are you or have you taken:
Do you have or have you had:
Blood transfusion; Date ________ Are you on birth control pills
Are you required/did you take medication (as prescribed by American Heart Assoc.) prior to treatment: Y__ N__
Do you have a history of taking drugs for osteoporosis or cancer therapy? Y___N___ Commonly
IV: pamidronate (Aredia), zoledronate (Zometa) (Reclast)
ORAL: alendronate (Fosamax), Ibandronate (Boniva), Risedronate (Actonel)
Do you regularly take supplements or herbal medicines? Y___N___ If yes do you regularly take any of the following?
Vitamin E >400 units, Fish Oil >3g, Echinacea, Ephedra, Garlic, Ginkgo Biloba,
Ginseng, Kava Kava, St. John’s Wort, Valerian
Have you recently stopped taking any herbs? Y___N___
Have you substituted any herbs for prescription or over the counter drugs? Y___N___
Please describe any current medical treatment including all current drugs/medications, pending
surgery, recent injuries or any other information we should be aware of that we have not discussed:
To the best of my knowledge, the above information is complete and correct. I will not hold my dentist or any
other member of his/her staff responsible for any errors or omissions that I may have made in the completion of
I understand that a 1.5% Service Charge may be assessed on the unpaid balance of 60 days and over, and
also liable for legal and collection fees. I understand that I am responsible for payment in full upon completion of each
procedure. My insurance will be billed, if applicable, however, I am responsible for all charges not covered by my
Signature of patient
IN THE ARMED FORCES TRIBUNAL REGIONAL BENCH, GUWAHATI. T.A. NO. 14 OF 2010 (Arising out of Writ Petition (C) No. 1911/2007) HON’BLE MR. JUSTICE H.N.SARMA, Member (J) HON’BLE CMDE MOHAN PHADKE (Retd), Member (A) Lt.Col( retd) G.C.L.Arokiadas Son of Late S.Guru swami Station Cell HQ 51 SUB AREA Narengi Cantt. PO Satgaon,Guwahti-781027,Assam. Mr.A.Ahmed Legal Practit
GAZZETTA UFFICIALE DELLA REPUBBLICA ITALIANA Serie generale - n . 238 Lo studio AD 2000, finanziato dal servizio sanitario britannico, merita una considerazione particolare in quanto ha il follow-up più lungo mai realizzato su pazienti affetti da AD in trattamento con inibitori dell’AChE (3 anni), ed è uno dei pochi RCT pubblicati ad avere considerato come outcome primario il ris